Volunteer Information

First Name (required)

Last Name (required)

Date of Birth

Street Address

City

State

Zip Code

Preferred Phone

Email (Required)

Employer, School or Group name

Electronic Signature

CONFIDENTIALITY: As a volunteer with Northern Virginia Family Service (NVFS), I understand that any staff, client, volunteer or project-related information (written or verbal) for which I gain knowledge must be held in strictest confidence and not shared outside of NVFS. I will respect the rights and privacy of all information pertaining to written consent of the appropriate NVFS authority.

PRIVACY OF INFORMATION: I understand that the information I have disclosed on this form will remain confidential to NVFS. Furthermore, I understand that, by providing my email, I will be subscribed to the monthly Volunteer Voice and NVFS Insider e-newsletters and will have the option to unsubscribe should I so choose.

RELEASES: NVFS’ priority is the safety of our clients and program participants. In order to ensure the safety of NVFS participants, NVFS reserves the right to conduct background checks on volunteers, who will work with children, or may come in contact with children during the course of their volunteer experience. Such individuals will be required to maintain satisfactory records as a condition of volunteerism. In addition, NVFS may periodically perform background checks on volunteers who have been previously checked and who continue to be involved in a position with NVFS whereby NVFS policy would require such background checks of such individual. I hereby release NVFS from all liability for any damage whatsoever incurred in obtaining or furnishing such information.

By signing my name and dating this authorization, I hereby confirm the accuracy of the information provided above and grant NVFS the permission to do a background check, as NVFS deems necessary.

Based on the above, I agree to indemnify and hold harmless and release NVFS and its officers, employees and authorized representatives from and against any and all liability, loss, damage, costs (including attorney’s fees) arising out of or in any way attributed to the activities performed as an NVFS volunteer.

Furthermore, I give permission to NVFS, and/or parties designated by NVFS, to record the story and/or likeness of the person(s) named below and use such accounts in all forms of media, for any and all promotional purposes including brochures, television interviews, NVFS reports/press releases, radio/newspaper/newsletter interviews, photos, public service announcements, fundraising appeals, video production, NVFS website, social media sites and related internet marketing indefinitely, unless or until I revoke this permission in writing.

E-Signature (required)

Date (required)

If you are under 18, e-signature of parent/guardian